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EAP Client Intake Form

Intake Form

Please fill out this form to help us understand how we can best support you. All information is strictly confidential.

NEW EAP Client Intake Form

Client Details

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Full Name

Gender

Birth Date

May we email you?

Phone

Address

Marital Status

Pls list any children/age (or N/A if not applicable)

Have you previously received any type of mental health services (psychotherapy psychiatric services etc)

Previous Therapist/Practitioner

Are you currently taking any prescription medication?

If yes please list

Have you ever been prescribed psychiatric medication?

Please list and provide dates

1) How would you rate your current physical health?

Pls list any specific health problems you are currently experiencing

2) How would you rate your current sleeping habits?

Pls list any specific sleep problems you are currently experiencing

3) How many times per week do you genrally exercise? What types of exercise do you participate in?

4) Please list any difficulties you experience with your appetite or sleeping patterns

5) Are you currently experiencing ovewhelming sadness grief or depression? If yes for approximately how long?

6) Are you currently experiencing anxiety panic attacks or have phobias? If yes when did you begin experiencing this?

7) Are you currently experiencing chronic pain? If yes please describe

8) Do you drink alcohol more than once a week?

9) How often do you engage in recreational drug use?

How often do you engage in

10) Are you currently in a romantic relationship? If yes for how long?

How would you rate your relationship (1-Poor 10-Very Good)?

11) What significant life changes or stressful events have you experienced lately?

Family Mental Health History

Alcohol / substance

Abuse

Anixety

Depression

Domestic violence

Eating disorder

Obesity

Obsessive Compulsive behavior

Schizophrenia

Suicide attempts

1) Are you currently employed? Describe your current work situation Do you enjoy your work? Is there anything stressful about your work?

2) Do you consider yourself to be spiriual or religious? If yes describe your faith or belief

3) What do you consider to be some of your strengths?

4) What do you consider to be some of your weaknesses?

5) What would you like to accomplish out of your time in therapy?

Thank you!

We have received your submission. Someone from our team will be in touch. Thank you!

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Kairos Assist understands the importance of recognising the traditional owners of the lands on which we operate. We extend our respect to the Elders, both past and present, and acknowledge the unique and ongoing connection that native people have to this land.

Contacts:

Phone: 02 8502 8400 
Mobile: 0431 3145 99
Email: counselling@kairoscare.com.au 

Mailing Address:
PO Box 7214 Alexandria NSW 2015  

Address:
Western Sydney: 
Shop 3 & Suite 4, 115-117 Best Road Seven Hills NSW  2147 

South Sydney: 
Suite 3, 7-9 President Avenue Caringbah NSW 2229 

Working Hours:
We are open from Mondays to Fridays 8:00 AM - 6:00 PM.

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